Summary of Benefits 2026 PDF Free Download
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Summary of Benefits
2026
H1224_2026_MedProd_SBv2_M_Approved LA3967 09/25
1
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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Introduction
This document is a brief summary of the benets and services covered by L.A. Care Medicare Plus. It includes answers to frequently asked
questions, important contact information, an overview of benets and services oered, and information about your rights as a member of
L.A. Care Medicare Plus. Key terms and their denitions appear in alphabetical order in the last chapter of the Member Handbook.
Table of Contents
A. Disclaimers .............................................................................................................................2
B. Frequently asked questions (FAQ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
C. List of covered services .................................................................................................................13
D. Benets covered outside of L.A. Care Medicare Plus .....................................................................................33
E. Services that L.A. Care Medicare Plus, Medicare, and Medi-Cal do not cover ..............................................................34
F. Your rights as a member of the plan ....................................................................................................34
G. How to le a complaint or appeal a denied, delayed, or modied service .................................................................37
H. What to do if you suspect fraud ........................................................................................................38
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If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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A. Disclaimers
!
This is a summary of health services covered by L.A. Care Medicare Plus for 2026. This is only a summary. Please read the Member Handbook
for the full list of benets. The 2026 Member Handbook will be available by October 15, 2025 on our website at medicare.lacare.org. To get
a free copy by mail, call Member Services at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week, including holidays.
❖L.A. Care Medicare Plus (HMO D-SNP) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to
enrollees. Enrollment in L.A. Care Medicare Plus depends on contract renewal.
❖This is not a complete list. The benefits information is a brief summary, not a complete description of benefits. For more information, contact
the plan or read the L.A. Care Medicare Plus Member Handbook.
❖For more information about Medicare, you can read the Medicare & You handbook. It has a summary of Medicare benefits, rights, and
protections and answers to the most frequently asked questions about Medicare. You can get it at the Medicare website (www.medicare.gov)
or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. For more information
about Medi-Cal, you can check the California Department of Healthcare Services (DHCS) website (www.dhcs.ca.gov/) or contact the
Medi-Cal Office of the Ombudsman 1-888-452-8609, Monday through Friday, between 8:00 a.m. and 5:00 p.m. You can also call the special
Ombudsman for people who have both Medicare and Medi-Cal, at 1-855-501-3077, Monday through Friday, between 9:00 a.m. and 5:00 p.m.
❖Notice of Availability of Language Assistance Services and Auxiliary Aids and Services
• ATTENTION: If you need help in your language, call 1-833-522-3767 (TTY: 711).
Aids and services for people with disabilities, like documents in braille and large
print, are also available. Call 1-833-522-3767 (TTY: 711). These services are free.
(Arabic)
1-833-522-3767 (TTY: 711)
1-833-522-3767 (TTY: 711)
.
•
3
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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Հայերեն պիտակ (Armenian)
•ՈՒՇԱԴՐՈՒԹՅՈՒՆ: Եթե Ձեզ օգնություն է հարկավոր Ձեր լեզվով,
զանգահարեք 1-833-522-3767 (TTY: 711)։ Կան նաև օժանդակ միջոցներ ու
ծառայություններ հաշմանդամություն ունեցող անձանց համար, օրինակ`
Բրայլի գրատիպով ու խոշորատառ տպագրված նյութեր։ Զանգահարեք
1-833-522-3767 (TTY: 711)։ Այդ ծառայություններն անվճար են։
简体中文标语 (Chinese)
•请注意：如果您需要以您的母语提供帮助，请致电 1-833-522-3767 (TTY: 711)。
另外还提供针对残疾人士的帮助和服务，例如盲文和需要较大字体阅读，也是方
便取用的。请致电 1-833-522-3767 (TTY: 711)。这些服务都是免费的。
(Punjabi)
• : 1-833-522-3767
(TTY: 711). ,
, | 1-833-522-3767 (TTY: 711). |
(Hindi)
• :
1-833-522-3767 (TTY: 711)
, 1-833-522-3767
(TTY: 711) :
4
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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Nqe Lus Hmoob Cob (Hmong)
•CEEB TOOM: Yog koj xav tau kev pab txhais koj hom lus hu rau 1-833-522-3767
(TTY: 711). Muaj cov kev pab txhawb thiab kev pab cuam rau cov neeg xiam oob
qhab, xws li puav leej muaj ua cov ntawv su thiab luam tawm ua tus ntawv loj. Hu rau
1-833-522-3767 (TTY: 711). Cov kev pab cuam no yog pab dawb xwb.
日本語表記 (Japanese)
• 注意日本語での対応が必要な場合は 1-833-522-3767 (TTY: 711) へお電話くださ
い。点字 の資料や文字の拡大表示など、障がいをお持ちの方のためのサービス
も用意しています。1-833-522-3767 (TTY: 711) へお電話ください。これらのサー
ビスは無料で提供しています。
한국어 태그라인 (Korean)
• 유의사항: 귀하의 언어로 도움을 받고 싶으시면 1-833-522-3767 (TTY: 711)
번으로 문의하십시오. 점자나 큰 활자로 된 문서와 같이 장애가 있는 분들을
위한 도움과 서비스도 이용 가능합니다. 1-833-522-3767 (TTY: 711) 번으로
문의하십시오. 이러한 서비스는 무료로 제공됩니다.
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If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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ແທກໄລພາສາລາວ (Laotian)
•ປະກາດ:
້າທ
່ານ
້ອງການຄວາມ
່ວຍເ
ື�ອໃນພາສາຂອງທ
່ານໃ
້ໂທາເ
ີ
1-833-522-3767 (TTY: 711). ຍ
ັງມ
ີຄວາມ
່ວຍເ
ື�ອແລະການ
ໍລ
ິການສ
ໍາລ
ັຄ
ົນພ
ິການ
ເ
ັ່ນເອກະສານທ
ີ່ເປ
ັນອ
ັກສອນນ
ູນແລະມ
ີໂພ
ິມໃຍ
່ ໃ
້ໂທາເ
ີ 1-833-522-3767
(TTY: 711). ການ
ໍລ
ິການເ
ືົ່ານ
ີ້
ໍ່
້ອງເສຍຄ
່າໃ
້
່າຍໃດໆ.
Mien Tagline (Mien)
•LONGC HNYOUV JANGX LONGX OC: Beiv taux meih qiemx longc mienh tengx faan
benx meih nyei waac nor douc waac daaih lorx taux 1-833-522-3767
(TTY: 711). Liouh lorx jauvlouc tengx aengx caux nzie gong bun taux ninh mbuo
wuaaic fangx mienh, beiv taux longc benx nzangc-pokc bun hluo mbiutc aengx
caux aamz mborqv benx domh sou se mbenc nzoih bun longc. Douc waac daaih lorx
1-833-522-3767 (TTY: 711). Naaiv deix nzie weih gong-bou jauv-louc se benx wang-
henh tengx mv zuqc cuotv nyaanh oc.
(Cambodian)
• 1-833-522-3767
(TTY: 711)
1-833-522-3767 (TTY: 711)
❖
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If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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(Farsi)
1-833-522-3767 (TTY: 711)
1-833-522-3767 (TTY: 711)
Русский слоган (Russian)
•ВНИМАНИЕ! Если вам нужна помощь на вашем родном языке, звоните по номеру
1-833-522-3767 (TTY: 711). Также предоставляются средства и услуги для людей
с ограниченными возможностями, например документы крупным шрифтом или
шрифтом Брайля. Звоните по номеру 1-833-522-3767 (TTY: 711). Такие услуги
предоставляются бесплатно.
Mensaje en español (Spanish)
•ATENCIÓN: si necesita ayuda en su idioma, llame al 1-833-522-3767 (TTY: 711).
También ofrecemos asistencia y servicios para personas con discapacidades, como
documentos en braille y con letras grandes. Llame al 1-833-522-3767 (TTY: 711).
Estos servicios son gratuitos.
•
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If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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Tagalog Tagline (Tagalog)
•ATENSIYON: Kung kailangan mo ng tulong sa iyong wika, tumawag sa
1-833-522-3767 (TTY: 711). Mayroon ding mga tulong at serbisyo para sa mga taong
may kapansanan, tulad ng mga dokumento sa braille at malaking print. Tumawag sa
1-833-522-3767 (TTY: 711). Libre ang mga serbisyong ito.
แท็กไลน์ภาษาไทย(Thai)
•โปรดทราบ: หากคุณต้องการความช่วยเหลือเป็นภาษาของคุณ กรุณาโทรศัพท์ไปที่
หมายเลข 1-833-522-3767 (TTY: 711) นอกจากนี้ ยังพร้อมให้ความช่วยเหลือและบริการ
ต่าง ๆ สำาหรับบุคคลที่มีความพิการ เช่น เอกสารต่าง ๆ ที่เป็นอักษรเบรลล์และเอกสารที่
พิมพ์ด้วยตัวอักษรขนาดใหญ่ กรุณาโทรศัพท์ไปที่หมายเลข 1-833-522-3767 (TTY: 711)
ไม่มีค่าใช้จ่ายสำาหรับบริการเหล่านี้
Примітка українською (Ukrainian)
• УВАГА! Якщо вам потрібна допомога вашою рідною мовою, телефонуйте
на номер 1-833-522-3767 (TTY: 711). Люди з обмеженими можливостями
також можуть скористатися допоміжними засобами та послугами, наприклад,
отримати документи, надруковані шрифтом Брайля та великим шрифтом.
Телефонуйте на номер 1-833-522-3767 (TTY: 711). Ці послуги безкоштовні.
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If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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Khẩu hiệu tiếng Việt (Vietnamese)
•CHÚ Ý: Nếu quý vị cần trợ giúp bằng ngôn ngữ của mình, vui lòng gọi số
1-833-522-3767 (TTY: 711). Chúng tôi cũng hỗ trợ và cung cấp các dịch vụ dành cho
người khuyết tật, như tài liệu bằng chữ nổi Braille và chữ khổ ln (chữhoa). Vui lòng gọi
số 1-833-522-3767 (TTY: 711). Các dịch vụ này đều miễn phí.
❖You can get this document for free in other formats, such as large print, braille, or audio. Call 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days
a week, including holidays. The call is free.
❖This document is available for free in Arabic, Armenian, Chinese, Punjabi, Hindi, Hmong, Japanese, Korean, Laotian, Mien, Cambodian, Farsi,
Russian, Spanish, Tagalog, Thai, Ukrainian and Vietnamese. These versions are also available on our website at medicare.lacare.org.
❖You can ask that we always send you information in the language or format you need. This is called a standing request. We will keep track of
your standing request so you do not need to make separate requests each time we send you information. To get this document in a language
other than English and/or in an alternate format, please contact Member Services at (833) 522-3767, TTY: 711, 24 hours a day, 7 days a week,
including holidays. A representative can help you make or change a standing request.
9
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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B. Frequently asked questions (FAQ)
The following table lists frequently asked questions.
Frequently Asked Questions Answers
What’s a Medi-Medi Plan? A Medi-Medi Plan is a health plan that contracts with both Medicare and Medi-Cal to provide
benets of both programs to enrollees. It’s for people age 21 and older. A Medi-Medi Plan is an
organization made up of doctors, hospitals, pharmacies, providers of Long-term Services and
Supports (LTSS), and other providers. It also has care coordinators to help you manage all your
providers and services and supports. They all work together to provide the care you need.
Will I get the same Medicare and
Medi-Cal benets in L.A. Care
Medicare Plus that I get now?
You’ll get most of your covered Medicare and Medi-Cal benets directly from L.A. Care Medicare
Plus. You’ll work with a team of providers who will help determine what services will best meet
your needs. This means that some of the services you get now may change based on your needs,
and your doctor and care team’s assessment. You may also get other benets outside of your
health plan the same way you do now, directly from a State or county agency like In-Home
Supportive Services (IHSS), specialty mental health and substance use disorder services, or
regional center services.
When you enroll in L.A. Care Medicare Plus, you and your care team will work together to
develop an Individualized Plan of Care to address your health and support needs, reecting your
personal preferences and goals.
If you are taking any Medicare Part D drugs that L.A. Care Medicare Plus doesn’t normally
cover, you can get a temporary supply and we’ll help you to transition to another drug or get
an exception for L.A. Care Medicare Plus to cover your drug if medically necessary. For more
information, call Member Services or at the number listed at the bottom of this page.
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If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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Frequently Asked Questions Answers
Can I use the same doctors I use now? Often that’s the case. If your providers (including doctors, hospitals, therapists, pharmacies, and
other health care providers) work with L.A. Care Medicare Plus and have a contract with us, you
can keep going to them.
•Providers with an agreement with us are “in-network.” Network providers participate in our
plan. That means they accept members of our plan and provide services our plan covers.
You must use the providers in L.A. Care Medicare Plus’s network. If you use providers or
pharmacies that aren’t in our network, the plan may not pay for these services or drugs.
•If you need urgent or emergency care or out-of-area dialysis services, you can use providers
outside of L.A. Care Medicare Plus’s plan.
•If you’re currently under treatment with a provider that’s out of L.A. Care Medicare Plus’s network,
or have an established relationship with a provider that’s out of L.A. Care Medicare Plus’s network,
call Member Services to check about staying connected and ask for continuity of care.
To be eligible for Continuity of Care (COC):
ºYou must have seen the Primary Care Physician (PCP) and/or Specialist at least once
during the last 12 months and have an upcoming appointment with the PCP or
Specialist within the next 12 months.
ºYour Provider must be willing to accept the L.A. Care Health Plan rates and contract with
the appropriate Medical Group/IPA.
ºYour provider must not have any documented quality of care concerns that would
cause L.A. Care or PPG to exclude the provider from its network.
Each continuity of care request must be completed within:
ºThirty (30) calendar days from the date L.A. Care or PPG receives the request;
ºFifteen (15) calendar days if the member’s medical condition requires more immediate
attention, such as upcoming appointments or other pressing care needs; or
ºThree (3) calendar days if there is risk of harm to the member
To nd out if your doctors are in the plan’s network, call Member Services at the numbers listed
at the bottom of this page or read LA. Care Medicare Plus’s Provider and Pharmacy Directory on
the plan’s website at medicare.lacare.org.
If L.A. Care Medicare Plus is new for you, we’ll work with you to develop an Individualized Plan of
Care to address your needs.
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If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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Frequently Asked Questions Answers
What’s a L.A. Care Medicare Plus
Care Manager?
A L.A Care Medicare Plus Care Manager is one main person for you to contact. This person helps
to manage all your providers and services and make sure you get what you need.
What are Long-term Services
and Supports (LTSS)?
Long-term Services and Supports (LTSS) are help for people who need assistance to do everyday
tasks like bathing, toileting, getting dressed, making food, and taking medicine. Most of these
services are provided at your home or in your community but could be provided in a nursing
home or hospital. In some cases, a county or other agency may administer these services, and
your care coordinator or care team will work with that agency.
What’s a Multipurpose Senior
Services Program (MSSP)?
A MSSP provides on-going care coordination with health care providers beyond what your
health plan already provides and can connect you to other needed community services and
resources. This program helps you get services that help you live independently in your home.
What happens if I need a service but
no one in L.A. Care Medicare Plus’
network can provide it?
Most services will be provided by our network providers. If you need a service that can’t be provided
within our network, L.A. Care Medicare Plus will pay for the cost of an out-of-network provider.
Where’s L.A. Care Medicare Plus
available?
The service area for this plan includes: Los Angeles County, California. You must live in this area
to join the plan.
What’s prior authorization? Prior authorization means an approval from L.A. Care Medicare Plus to seek services outside of
our network or to get services not routinely covered by our network before you get the services.
L.A. Care Medicare Plus may not cover the service, procedure, item, or drug if you don’t get
prior authorization.
If you need urgent or emergency care or out-of-area dialysis services, you don’t need to
get prior authorization rst. L.A. Care Medicare Plus can provide you or your provider with a
list of services or procedures that require you to get prior authorization from L.A. Care Medicare
Plus before the service is provided. If you have questions about whether prior authorization
is required for specic services, procedures, items, or drugs, call Member Services or at the
numbers listed at the bottom of this page for help.
12
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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Frequently Asked Questions Answers
What’s a referral? A referral means that your primary care provider (PCP) must give you approval to go to someone
that’s not your PCP. A referral is dierent than a prior authorization. If you don’t get a referral
from your PCP, L.A. Care Medicare Plus may not cover the services. L.A. Care Medicare Plus can
provide you with a list of services that require you to get a referral from your PCP before the
service is provided.
Refer to the Member Handbook to learn more about when you’ll need to get a referral from your PCP.
Do I pay a monthly amount (also
called a premium) under L.A. Care
Medicare Plus?
No. Because you have Medi-Cal, you won’t pay any monthly premiums, including your Medicare
Part B premium, for your health coverage.
Do I pay a deductible as a member of
L.A. Care Medicare Plus?
No. You don’t pay deductibles in L.A. Care Medicare Plus.
What’s the maximum out-of-pocket
amount that I will pay for medical
services as a member of L.A. Care
Medicare Plus?
There’s no cost sharing for medical services in L.A. Care Medicare Plus, so your annual out-of-
pocket costs will be $0.
What happens if I lose
Medi-Cal eligibility?
If you are within our plan’s 3-month period of deemed continued eligibility, we will continue to
provide all Medicare Advantage plan-covered Medicare benets. However, during this period,
we will not continue to cover Medicaid benets that are included under the applicable Medicaid
State Plan, nor will we pay the Medicare premiums or cost sharing for which the state would
otherwise be liable had you not lost your Medicaid eligibility. Your cost for services may change,
please reference the Member Handbook for more information.
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If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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C. List of covered services
The following table is a quick overview of what services you may need, your costs, and rules about the benets.
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
You need
hospital care
Hospital stay $0 Hospital services are covered when determined to be
medically necessary by your treating doctor and L.A. Care
Medicare Plus. There are no limits to the number of medically
necessary covered days for each hospital stay.
Except in an emergency, your doctor must tell the plan
that you are going to be admitted to the hospital. You
must go to network doctors, specialists, and hospitals.
Prior authorization may be required for network hospitals
non-emergency procedures.
Doctor or surgeon care $0 Doctor and surgeon care are provided as part of your
hospital stay. Prior authorization rules and referral
requirements may apply.
Outpatient hospital services,
including observation
$0
Ambulatory surgical center
(ASC) services
$0 Prior authorization rules and referral requirements
may apply.
14
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
You want a doctor Visits to treat an injury
or illness
$0 You must go to network doctors, specialists, and hospitals.
If you need urgent or emergency care or out-of-area
dialysis services, you don’t need to get approval rst.
Specialist care $0 You must go to network doctors, specialists, and hospitals.
Prior authorization and referral required for network
specialist and hospitals.
Wellness visits, such as
a physical
$0 Annual Wellness Visit every 12 months.
Care to keep you from getting
sick, such as u shots and
screenings to check for cancer
$0 Prior authorization rules requirements may apply.
Acupuncture
(Medicare Covered)
$0 Limit of two visits each month. More visits may be
allowed with prior authorization if medically necessary.
For Medicare-covered acupuncture visits: Up to 12
acupuncture visits in 90 days if you have chronic low back
pain. An additional 8 sessions of acupuncture for chronic
low back pain if you show improvement. You may not get
more than 20 acupuncture treatments for chronic low
back pain each year. Acupuncture treatments for chronic
low back pain must be stopped if you don’t get better or
if you get worse.
Prior authorization rules and referral requirements
may apply.
“Welcome to Medicare”
(preventive visit one time only)
$0 During the rst 12 months of your new Part B coverage,
you can get either a Welcome to Medicare Preventive Visit
or an Annual Wellness Visit. After your rst 12 months, you
can get one Annual Wellness Visit every 12 months.
15
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
You need
emergency care
Emergency room services $0 You may get covered emergency medical care whenever
you need it, anywhere in the United States or its
territories, without prior authorization or referral.
Emergency and urgently needed services received
outside of the United States and its territories are covered
up to $10,000 combined per calendar year.
Urgent care $0 You may get covered urgent care whenever you need it,
anywhere in the United States or its territories without
prior authorization or referral.
Choose an urgent care center that works with your
medical group. You can nd your medical group on your
member ID card.
Emergency and urgently needed care services received
outside the United States are covered to a limit of $10,000
combined per calendar year.
You need
medical tests
Diagnostic radiology services
(for example, X-rays or other
imaging services, such as CAT
scans or MRIs)
$0 Prior authorization rules and referral requirements
may apply.
Lab tests and diagnostic
procedures, such as blood
work
$0 Prior authorization rules and referral requirements
may apply.
No prior authorization or referral required for COVID-19
testing related services.
You need hearing/
auditory services
Hearing screenings $0 Referral requirements may apply.
Hearing aids $0
16
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
You need dental
care (continued on
the next page)
Dental check-ups and
preventive care
$0 Our plan covers dental services and procedures including:
• Oral Exams – 1 every year
• Cleanings – 1 every year
• Fluoride Treatment – 1 topical application
• X-Rays – 1 every year
Our plan partners with Liberty Dental to provide your
dental benets. Benets exclusions and limitations may
apply. There may be exceptions if medically necessary.
To locate a network dentist you may call Member Services
at 1-855-552-8243 or search the online dental provider
directory at medicare.lacare.org. It is recommended that
you work with your in-network dentist to check benet
coverage prior to obtaining dental services. If you choose
to use a dentist outside of the network, the services you
receive will not be covered by our plan.
Additional dental services, such as check-ups and
preventive care are available through the Medi-Cal Dental
Program. For more information you can visit the website
at dental.dhcs.ca.gov/.
As of July 1, 2026, dental benets will no longer be
available to members who do not meet satisfactory
immigration status requirements.
17
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
You need dental
care (continued
from previous
page)
Restorative and emergency
dental care
$0 Our plan covers dental services and procedures including
the following:
• Restorative
• Endodontics – 1 per tooth per lifetime
• Periodontics
• Prosthodontics (Fixed and Removable)
• Oral/Maxillofacial Surgery
• Adjunctive General Services
Our plan partners with Liberty Dental to provide your
dental benets. Benets exclusions and limitations may
apply. There may be exceptions if medically necessary.
To locate a network dentist you may call Member Services
at 1-855-552-8243 or search the online dental provider
directory at medicare.lacare.org. It is recommended that
you work with your in-network dentist to check benet
coverage prior to obtaining dental services. If you choose
to use a dentist outside of the network, the services you
receive will not be covered by our plan.
Prior authorization rules are listed in the Member
Handbook and referral requirements may apply.
Dental services are available through the Medi-Cal Dental
Program. For more information you can visit the website
at dental.dhcs.ca.gov/.
As of July 1, 2026, dental benets will no longer be
available to members who do not meet satisfactory
immigration status requirements.
18
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
You need eye care Eye exams $0 Medically necessary vision exams for the diagnosis and
treatment of diseases and conditions of the eye, including
an annual glaucoma screening for people at risk.
Referral requirements may apply.
Up to 1 supplemental routine eye exam every year
Glasses or contact lenses $0 Your routine vision benets include:
• One routine eye exam per calendar year
• Up to $500 toward one pair of eyeglasses (frames
only) or contact lenses every two calendar years
• Basic Prescription lenses are covered such as glass
or plastic, single vision, lined bifocal, lined trifocal, or
lenticular lenses every two calendar years. Upgrades
and enhancements such as progressive lens, scratch
resistance coatings, other coatings and additions are
not covered.
Note: Basic Prescription lenses do not count towards the
$500 allowance.
To nd out more about vision care covered through
L.A. Care Medicare Plus, please call 1-855-492-9028
(TTY 711) 8:00 a.m. to 8:00 p.m., 7 days a week
or visit their provider directory on our website at:
www.vsp.com/advantageonly
Prior Authorizations may apply for routine eye exam.
Other vision care $0
19
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
You need mental
health services
(continued on the
next page)
Mental health services $0 Coverage includes:
• Individual therapy
• Group therapy
• Family Therapy
• Psychiatric consultation
• Psychological and neuropsychological testing
when clinically indicated to evaluate a mental
health condition
Additional specialty mental health services are available
to you through the Los Angeles County Department of
Mental Health. Coverage includes:
• Crisis intervention
• Day treatment intensive services
• Targeted case management
To access these services, you can call the L.A. County
Help Line at 1-800-854-7771. Someone is available to
assist you 24/7.
Prior authorization rules may apply. However, no
prior authorization is required for an initial mental
health assessment.
20
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
You need mental
health services
(continued from
previous page)
Inpatient and outpatient care
and community-based services
for people who need mental
health services
$0 You get up to 190 days of inpatient psychiatric hospital
care in a lifetime. Inpatient psychiatric hospital services
count toward the 190-day lifetime limitation only if
certain conditions are met. This limitation does not
apply to inpatient psychiatric services furnished in a
general hospital.
Plan covers 90 days for an inpatient hospital stay.
Plan covers 60 lifetime reserve days. $0 co-pay per
lifetime reserve day.
Except in an emergency, your doctor must tell the plan
that you are going to be admitted to the hospital.
Once these benets are exhausted, inpatient services will
be pursued through the County Specialty Mental Health
Provider through your Medi-Cal coverage.
Prior Authorization rules may apply.
21
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
You need a
substance use
disorder services
Substance use
disorder services
$0 Substance Use includes*:
• Outpatient Treatment
• Intensive Outpatient Treatment
• Case Coordination
• Medication Assisted Treatment (MAT)
• Withdrawal Management (also known as Detox)
• Recovery Bridge Housing
• Recovery Support Services
• Residential Treatment
Prior authorization may be applicable for some services.
*Some services are carved out to the Los Angeles
County Department of Public Health, Substance Abuse
Prevention and Control.
To access these services, you can call the L.A. County
Help Line at 1-800-854-7771. Someone is available to
assist you 24/7.
You need a
place to live with
people available
to help you
Skilled nursing care $0 Skilled Nursing Facility (SNF)
Coordination by your doctor, prior authorization rules and
referral requirements may apply.
No limit to the number of days covered by the plan for
each SNF stay.
Home Health Care
Includes medically necessary short term intermittent
skilled nursing care and rehabilitation services.
Prior authorization rules and referral requirements may apply.
Nursing home care $0 Prior authorization rules and referral requirements may apply.
Adult Foster Care and Group
Adult Foster Care
$0
22
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
You need
therapy after a
stroke or accident
Occupational, physical, or
speech therapy
$0 Medically necessary physical therapy, occupational
therapy, and speech and language pathology services
are covered while you are in the hospital and skilled
nursing facility.
Prior authorization and referral requirements may apply
for continued services upon discharge.
You need help
getting to
health services
Ambulance services $0 Prior authorization is not required for in-network and out-
of-network emergency ambulance services.
For non-emergency ambulance services, prior
authorization may apply.
Emergency transportation $0
Transportation to medical
appointments and services
$0 Routine Transportation
Referral requirements may apply.
Unlimited round-trips to plan-approved locations
every year.
Non-Emergency Medical Transportation
Contact L.A. Care Medicare Plus or refer to the Member
Handbook for more details.
23
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
You need drugs to
treat your illness
or condition
Medicare Part B drugs $0 Part B drugs include drugs given by your doctor in their
oce, some oral cancer drugs, and some drugs used with
certain medical equipment. Read the Member Handbook
for more information on these drugs.
Prior authorization rules may apply.
Medicare Part D drugs
Tier 1: Preferred Generic
Tier 2: Generic
Tier 3: Preferred Brand
Tier 4: Non-Preferred Drug
Tier 5: Specialty Tier
$0-$12.65 or 25% for a
30-day supply.
Copays/Coinsurance for
drugs may vary based on
the level of Extra Help you
get. Please contact the plan
for more details.
There may be limitations on the types of drugs covered.
Please refer to L.A. Care Medicare Plus’s List of Covered
Drugs (Drug List) for more information. Once you or
others on your behalf pay $2,100 you have reached the
catastrophic coverage stage and you pay $0 for all your
Medicare drugs. Read the Member Handbook for more
information on this stage.
Tiers 1: $0 Copay
Tiers 2-5: $0-$12.65 or 25% Coinsurance
Your copay/Coinsurance depends on the amount of Extra
Help you receive.
For some covered Medicare Part D drugs, extended-
day supplies (100 days) are available at network retail
pharmacies or through mail order. The cost sharing
amount for these extended-day supplies is the same as
for a one-month supply.
24
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
You need help
getting better
or have special
health needs
Rehabilitation services $0 Outpatient Rehabilitation Services
Medically necessary physical therapy, occupational
therapy, and speech and language pathology services
are covered.
Coordination by your doctor, prior authorization rules and
referral requirements may apply.
Contact L.A. Care Medicare Plus for details.
Cardiac and Pulmonary Rehabilitation Services
Coordination by your doctor, prior authorization rules and
referral requirements may apply.
Medical equipment for
home care
$0 Prior authorization rules may apply.
Contact L.A. Care Medicare Plus for details.
Dialysis services $0 Dialysis in a center or in the home is covered when
prescribed by a licensed provider.
Out of Area Dialysis (provided outside of your county
but in the United States)
Is covered with prior approval, when the Medicare
licensed center has space and enough information about
you to give you the right treatment. A L.A. Care Medicare
Plus Care Manager and your dialysis center social worker
will help you locate a dialysis center when you are traveling.
Prior authorization and referral rules may apply.
Contact L.A. Care Medicare Plus for details.
25
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
You need foot care Podiatry services $0 Medicare covered podiatry visits are limited to foot exams
and treatment if you have diabetes-related nerve damage
and/or meet certain conditions.
Prior authorization rules and referral requirements
may apply.
Orthotic services $0 Prior authorization rules may apply.
You need
durable medical
equipment (DME)
Note: This is not
a complete list of
covered DME. For
a complete list,
contact Member
Services or refer
to Chapter 4
of the Member
Handbook.
Wheelchairs, crutches,
and walkers
$0 Provided when medically necessary and prescribed by a
licensed provider.
Prior authorization rules may apply.
Contact L.A. Care Medicare Plus for details.
Nebulizers $0 Provided when medically necessary and prescribed by a
licensed provider.
Prior authorization rules may apply.
Contact L.A. Care Medicare Plus for details.
Oxygen equipment
and supplies
$0 Provided when medically necessary and prescribed by a
licensed provider.
Prior authorization rules may apply.
Contact L.A. Care Medicare Plus for details.
26
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
You need help
living at home
Home health services $0 Prior authorization rules and referral requirements
may apply.
Contact L.A. Care Medicare Plus for details.
Home services, such as
cleaning or housekeeping, or
home modications such as
grab bars
$0 Prior authorization rules may apply.
Contact L.A. Care Medicare Plus for details.
For MSSP or IHSS-eligible members.
Adult day health, Community
Based Adult Services (CBAS), or
other support services
$0 Prior authorization rules and referral requirements
may apply.
Contact L.A. Care Medicare Plus for details.
Day habilitation services $0
Services to help you live on
your own (home health care
services or personal care
attendant services)
$0 Prior authorization rules and referral requirements
may apply.
Contact L.A. Care Medicare Plus for details.
27
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
Additional
services
(continued on the
next page)
Chiropractic services
(Medicare Covered)
$0
Case Management $0 Referral requirements may apply.
Contact L.A. Care Medicare Plus for details.
Diabetes supplies and services $0 Diabetes self-management training; Diabetes monitoring
supplies; Therapeutic shoes or inserts.
Diabetic Supplies and Services are limited to specic
manufacturers, products and/or brands. Contact the plan
for a list of covered supplies.
Prior authorization rules may apply.
SilverSneakers® Fitness Benet $0 L.A. Care Medicare Plus oers a tness benet
through SilverSneakers.
SilverSneakers is a tness benet that can help you
live a healthier, more active life through tness and
social connection
•SilverSneakers® oers access to a nationwide network
of participating gym and community locations where
you can take classes and use exercise equipment and
other amenities. Enroll in as many locations as you like,
at any time. You also have access to instructors who
lead specially designed group exercise classes
in-person and online, seven days a week.
SilverSneakers is a registered trademark of Tivity Health,
Inc. © 2025 Tivity Health, Inc. All rights reserved.
28
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
Additional
services
(continued from
the previous page)
Benets Prepaid
Card Allowance
$0 You will receive a $110 monthly allowance, preloaded on
your Benets Mastercard® Prepaid Card, to use for approved
over-the-counter (OTC) health and wellness items such
as cough and cold medicine, vitamins, pain relievers,
bandages, and more. The card and activation instructions
will be mailed to you about 7 to 10 days after joining the
plan. You will also receive OTC catalog in the mail, which
list all approved items. Once your coverage begins and the
card is activated, you can start placing orders. Shipping is
free, and most items arrive within about two days.
Getting your items is easy! You can use your Benets
Mastercard® Prepaid Card in-store at participating
pharmacies and retail locations, online, or by phone.
Only approved items are covered by the allowance. You
can use the printed catalog or visit lacare.nationsbenet.
com to check which products are eligible. Please note
that any unused funds do not carry over to the next
month. To make the most of your benet, it’s a good
idea to use the full allowance each month. For more
information, please refer to the Member Handbook. To
learn how to use these benets, contact NationsBenets®
at 1-833-571-7587 (TTY: 711) or visit NationsBenets at
LACare.NationsBenets.com
For more information on how to use these
benets, contact NationsBenets® at
1-833-571-7587 (TTY: 711) or visit NationsBenets
at LACare.NationsBenets.com
Personal Emergency
Response System (PERS)
$0
29
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
Additional
services
(continued from
the previous page)
Prosthetic services $0 Prior authorization rules may apply.
Routine Acupuncture and
Chiropractic Services
$0 You are covered for up to 45 visits per year (combined) for
routine acupuncture and routine chiropractor visits with
a participating provider. This combined benet is oered
in addition to your Medicare and Medi-Cal covered
acupuncture and chiropractic service treatments for
medical necessity.
Routine Podiatry $0 You are covered for up to 14 visits per year
Telehealth Services $0
Annual Physical Exam $0 You are covered for 1 visit per year
Wellness/Education and
Other Supplemental Benets
and Services
$0 The plan covers the following supplemental health and
wellness education services and programs:
• Nurse Advice Line
30
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
Additional
services
(continued from
the previous page)
Meal Benet $0 Meals as Medicine
L.A. Care’s Meals As Medicine program helps Members
learn about healthy foods and good eating habits. It also
oers home delivered meals or healthy food items that
can be prepared at home. When you join, you get:
• Healthy food tailored to your health needs.
• Food sent to your home.
• At least 2 meals per day or 1 food box for up to
12 weeks based on your health needs and goals.
• Time with a nutrition expert to learn more about
healthy eating.
To join the program, you must have a health condition
that can be helped by a special diet. This may include
diabetes, kidney disease, high blood pressure or other
conditions of the heart. An L.A. Care Registered Dietitian
will ask you some questions to see if this program is right
for you. During the program, you must be able to receive
a food delivery every week. You will also need to store
and prepare the meals properly. To learn more, call the
Meals As Medicine program at (855) 856-6943.
31
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
Additional
services
(continued from
the previous page)
Radiation therapy $0
Services to help manage
your disease
$0
Special Supplemental Benets
for the Chronically Ill (SSBCI)
$0 The Special Supplemental Benets for the Chronically Ill
(SSBCI) is a program that gives extra help to people who
have serious, long-term health problems. It’s designed to
make daily life easier and help members take better care
of their health at home. If you qualify, you can use the
$110 monthly allowance on your Benets Mastercard to
purchase approved items beyond just over-the-counter
(OTC) non-prescription health and wellness products.
You will also be able to pay for Healthy Foods, Utilities
Assistance and Automotive gasoline (Gas at the Pump).
To qualify for SSBCI, members must have one or more
chronic conditions that meet eligibility criteria. Some
examples include, but are limited to, Cardiovascular
Disorders, Diabetes, Chronic Kidney Disease (CKD),
Chronic and Disabling Mental Health Conditions, COPD,
and other chronic conditions listed in the Member
Handbook. Eligible members must also have serious
long-term health issues that impact daily life, be at high
risk for hospitalization or other major health problems
and require signicant assistance to manage their care.
Responses from your Health Risk Assessment (HRA)
and your medical records are used to help determine
if you qualify. You can also ask your doctor to submit a
request to L.A. Care that veries your qualifying medical
condition(s) and other eligibility criteria for SSBCI. Please
remember that the SSBCI benet and your qualications
(when approved) ends at the end of the benet year. Not
everyone will qualify.
32
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
Health need
or concern Services you may need Your costs for
in-network providers Limitations, exceptions, & benefit information
(rules about benefits)
Additional
services
(continued from
the previous page)
California Integrated Care
Management (CICM)
$0 L.A. Care recognizes the vulnerability of members
who would otherwise be eligible for Enhanced Care
Management (ECM). L.A. Care will identify members who
may be eligible to receive CICM who meet the California
Department of Health Care Services (DHCS)-prescribed
eligibility criteria for the 8 populations of focus below.
The member’s Health Risk Assessment may also be used
to assisting in determining eligibility:
• Adult Nursing Facility Residents Transitioning to the
Community
• Members At Risk for Avoidable Hospital or
Emergency Department Utilization
• Adults Living in the Community and At Risk for Long
Term Care (LTC) Institutionalization
• Adults Experiencing Homelessness
• Adults with Serious Mental Health and/or Substance
Use Disorder (SUD) Needs
• Adults Transitioning from Incarceration
• Adults who are Pregnant or Postpartum and Subject
to Racial and Ethnic Disparities as dened by
California public health data on maternal morbidity
and mortality (Birth Equity)
• Adults with Documented Dementia Needs
Through CICM, the assigned Care Manager still acts as a
single point of contact for members and/or caregivers to
help identify available or alternative services that target
member’s specic needs and identies interventions
that are tailored to the member based on the member’s
current level of services and support.
The above summary of benets is provided for informational purposes only and is not a complete list of benets. For a complete list and
more information about your benets, you can read the L.A. Care Medicare Plus Member Handbook. If you don’t have an Member Handbook,
call L.A. Care Medicare Plus Member Services at the number listed at the bottom of this page to get one. If you have questions, you can also call
Member Services or visit medicare.lacare.org.
33
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
?
D. Benefits covered outside of L.A. Care Medicare Plus
There are some services that you can get that aren’t covered by L.A. Care Medicare Plus but are covered by Medicare, Medi-Cal, or a State or
county agency. This is not a complete list. Call Member Services at the number listed at the bottom of this page to nd out about these services.
Other services covered by Medicare, Medi-Cal, or a State Agency Your costs
Certain dental services
Dental Managed Care (DMC) member contact information can be found at www.dental.dhcs.ca.gov/
Contact_Us/DMC_Member_Contact_Information/DMCMemberContactInformation.
For Medi-Cal Dental Fee-for-Service, contact Medi-Cal Dental at 1-800-322-6384 or visit the website at
smilecalifornia.org or sonriecalifornia.org.
$0
Certain hospice care services covered outside of L.A. Care Medicare Plus $0
Psychosocial rehabilitation $0
Targeted case management $0
Rest home room and board $0
In-Home Supportive Services (IHSS) Program $0
Specialty Mental Health and Substance Use Disorder $0
Assisted Living $0
Multipurpose Senior Services Program (MSSP) $0
Regional Center Services $0
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If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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E. Services that L.A. Care Medicare Plus, Medicare, and Medi-Cal do not cover
This is not a complete list. Call Member Services at the number listed at the bottom of this page to nd out about other excluded services.
Services L.A. Care Medicare Plus, Medicare, and Medi-Cal do not cover
Couples therapy
Certain durable medical equipment (DME) such as stairway elevators,
dehumidiers, telephone alert systems, and whirlpool baths. If you
have questions or are unsure if your DME is covered, please contact
Member Services for more information.
In vitro fertilization (IVF), including but not limited to infertility
studies or procedures to diagnose or treat infertility
Fertility preservation
Experimental services Home modications
Vehicle modications Cosmetic surgery
F. Your rights as a member of the plan
As a member of L.A. Care Medicare Plus, you have certain rights. You can exercise these rights without being punished. You can also use these
rights without losing your health care services. We’ll tell you about your rights at least once a year. For more information on your rights, please
read the Member Handbook. Your rights include, but are not limited to, the following:
• You have a right to respect, fairness, and dignity. This includes the right to:
ºGet covered services without concern about medical condition, health status, receipt of health services, claims experience, medical history,
disability (including mental impairment), marital status, age, sex (including sex stereotypes and gender identity), sexual orientation,
national origin, race, color, religion, creed, or public assistance
ºGet information in other languages and formats (for example, large print, braille, or audio) free of charge
ºBe free from any form of physical restraint or seclusion
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If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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•You have the right to get information about your health care. This includes information on treatment and your treatment options. This
information should be in a language and format you can understand. This includes the right to get information on:
ºDescription of the services we cover
ºHow to get services
ºHow much services will cost you
ºNames of health care providers
• You have the right to make decisions about your care, including refusing treatment. This includes the right to:
ºChoose a primary care provider (PCP) and change your PCP at any time during the year
ºUse a women’s health care provider without a referral
ºGet your covered services and drugs quickly
ºKnow about all treatment options, no matter what they cost or whether they are covered
ºRefuse treatment, even if your health care provider advises against it
ºStop taking medicine, even if your health care provider advises against it
ºAsk for a second opinion. L.A. Care Medicare Plus will pay for the cost of your second opinion visit
ºMake your health care wishes known in an advance directive
• You have the right to timely access to care that does not have any communication or physical access barriers. This includes the right to:
ºGet timely medical care
ºGet in and out of a health care provider’s oce. This means barrier-free access for people with disabilities, in accordance with the Americans
with Disabilities Act
ºHave interpreters to help with communication with your health care providers and your health plan
• You have the right to seek emergency and urgent care when you need it. This means you have the right to:
ºGet emergency services without prior authorization in an emergency
ºUse an out-of-network urgent or emergency care provider, when necessary
36
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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•You have a right to condentiality and privacy. This includes the right to:
ºAsk for and get a copy of your medical records in a way that you can understand and to ask for your records to be changed or corrected
ºHave your personal health information kept private
• You have the right to le a complaint or appeal a denied, delayed, or modied service, please see section G below. This includes the
right to:
ºFile a complaint or grievance against us or our providers
ºAppeal certain decisions made by us or our providers
ºFile a complaint with the California Department of Managed Health Care (DMHC) through a toll-free phone number (1-888-466-2219),
or a TDD line (1-877-688-9891) for the hearing and speech impaired. The DMHC website (www.dmhc.ca.gov/) has complaint forms,
Independent Medical Review (IMR) application forms, and instructions available online.
ºAsk DMHC for an IMR of Medi-Cal services or items that are medical in nature
ºAsk for a State Hearing
ºGet a detailed reason for why services were denied and ask for free copies of all the information used to make the decision
For more information about your rights, you can read the Member Handbook. If you have questions, you can call L.A. Care Medicare Plus Member
Services at the number listed at the bottom of this page.
You can also call the special Ombudsman for people who have Medicare and Medi-Cal at 1-855-501-3077, Monday through Friday, between
9:00 a.m. and 5:00 p.m., or the Medi-Cal Oce of the Ombudsman 1-888-452-8609, Monday through Friday, between 8:00 a.m. and 5:00 p.m.
37
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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G. How to file a complaint or appeal a denied, delayed, or modified service
If you have a complaint or think L.A. Care Medicare Plus improperly denied, delayed, or modied a service, call Member Services at the number
listed at the bottom of this page. You may also submit a complaint in writing to Appeals and Grievance Department 1200 West 7th Street
Los Angeles, CA 90017. You may be able to appeal our decision.
For questions about complaints and appeals, you can read Chapter 9 of the Member Handbook. You can also call L.A. Care Medicare Plus Member
Services at the number listed at the bottom of this page.
For complaints, grievances, and appeals you may also reach us by:
Fax: 1-213-438-5748
Mail: L.A. Care Medicare Plus
Attention: Appeals and Grievance -348
1200 W 7th Street
Los Angeles, CA 90017
Online: https://www.lacare.org/members/le-grievance/grievance-appeal-form
For complaints, grievances and appeals, you may also use the Department of Managed Health Care’s Independent Medical Review (IMR) and
Complaint process by:
Phone: 1-888-466-2219
TTY: 1-877-688-9891
Online: www.dmhc.ca.gov
The DMHC’s website has complaint forms, IMR application forms, and instructions online.
38
If you have questions, please call L.A. Care Medicare Plus at 1-833-522-3767 (TTY: 711), 24 hours a day, 7 days a week,
including holidays. The call is free. For more information, visit medicare.lacare.org.
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H. What to do if you suspect fraud
Most health care professionals and organizations that provide services are honest. Unfortunately, there may be some who are dishonest.
If you think a doctor, hospital or other pharmacy is doing something wrong, please contact us.
•Call us at L.A. Care Medicare Plus Member Services. Phone numbers are on the cover of this summary.
•Or, call the Medi-Cal Customer Service Center at 1-800-841-2900. TTY users may call 1-800-497-4648.
•Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users may call 1-877-486-2048. You can call these numbers for free.
•You can report fraud:
•Electronically at reportingfraud@lacare.org
•Anonymously on L.A. Care’s Fraud Hotline 1-800-400-4889
Toll Free: 1.833.522.3767 | TTY: 711 lacare.org
LA3967 09/25
If you have general questions or questions about our plan, services, service area,
billing, or Member ID Card, please call L.A. Care Medicare Plus Member Services:
1-833-522-3767
Calls to this number are free. 24 hours a day, 7 days a week, including holidays
Member Services also has free language interpreter services available for non-English speakers.
T T Y: 711
Calls to this number are free. 24 hours a day, 7 days a week, including holidays.
